Provider Demographics
NPI:1588834113
Name:TIDEWATER DIAGNOSTIC INTERPRETERS,INC
Entity Type:Organization
Organization Name:TIDEWATER DIAGNOSTIC INTERPRETERS,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:BASS
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-238-9401
Mailing Address - Street 1:PO BOX 5391
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-1391
Mailing Address - Country:US
Mailing Address - Phone:757-238-9401
Mailing Address - Fax:757-686-8156
Practice Address - Street 1:2994 CHURCHLAND BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5643
Practice Address - Country:US
Practice Address - Phone:757-484-5264
Practice Address - Fax:757-686-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA031305OtherANTHEM
CB8291OtherRAILROAD MEDICARE
CB8291OtherRAILROAD MEDICARE